SIX-MONTH CONTACT POINT - Nutrition International€¦ · six-month contact point. • IYCF counselling, whether provided at a six-month contact point or not, requires supportive
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BACKGROUND
Six months after birth represents an important time
to meet the nutrition and health needs of a mother
and her infant. For women, her fertility may return
at any time during the post-partum period,
increasing her risk of pregnancy. Even for women
practicing the lactational amenorrhea method
(LAM), the risk of pregnancy increases after six
months of age 1. For the six-month-old infant,
growth requirements call for added intake of
nutrient-rich foods to complement breast milk. It
also marks the start of the period when high-dose
VAS is likely to reduce infant mortality risk.
Creating a six-month postpartum contact within
the health system can provide an opportunity for
the timely delivery of an integrated package of
interventions showing high impact on both
maternal and child health and nutrition status 2.
Several countries have piloted this and are
beginning to scale it up. This brief describes the
rationale, process, results and lessons learned from
country experiences.
RATIONALE
Six months after birth is an important time for
meeting the nutrition, health and reproductive
needs of women and children, but few health
systems include a six-month contact point.
Establishing a six-month contact point may reduce
missed opportunity for saving lives, improving
infant and child feeding practices, improving
immunization coverage and spacing births.
SIX-MONTH CONTACT POINT A TIMELY WAY TO DELIVER ESSENTIAL MATERNAL AND CHILD HEALTH AND NUTRITION SERVICES INCLUDING VITAMIN A SUPPLEMENTATION (VAS)
KEY MESSAGES• Creating a six-month postpartum contact
point within the health system can provide
an opportunity for the timely delivery of
an integrated package of high-impact
interventions for both mother and child.• Experiences with six-month contact
points in Sierra Leone, Senegal and Côte
d’Ivoire show promising results in terms of
increasing the coverage of VAS, family
planning, counseling on infant and young
child feeding (IYCF) and catch-up
vaccinations at six months of age.
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• Saving lives with VAS at six-months of age: Six
months of age represents the start of the period
when VAS reduces mortality risk 3; yet the first
dose of vitamin A is often delivered to infants three
months late, during measles immunization (i.e.
measles-containing-vaccine first-dose or MCV1) or
Child Health Days (CHDs) 4. A recent modeling
study found an additional mortality benefit of 1.6%-
1.9% when VAS was provided to the child right at
the age of 6 months compared to at 9 months of
age during MCV1 or at another point between the
ages of 6-11 months 4. Caution is always needed to
avoid double-dosing in settings where many
vitamin A interventions target infants 6-11 months
of age, however, it also found the intervention to be
safe even if a second dose of VAS is given as soon
as 1 month after the first dose.
• Improving infant and young child feeding (IYCF)
practices: By the age of six months, a baby has
usually doubled its birth weight, and is becoming
more active. After six months of age, it becomes
increasingly difficult for breastfed infants to meet
their nutrient needs from human milk alone and
complementary foods should be introduced to
make up the difference 5. At about six months of
age, an infant is also developmentally ready for
other foods. The complementary feeding period
typically runs from 6-23 months of age and
represents a very vulnerable period as evidenced
by poor post-natal growth that contributes
significantly to the high prevalence of malnutrition
in children under five years of age worldwide. Thus,
six months after birth represents an important time
to provide mothers with counseling on appropriate
infant and young child feeding behaviors 6
including cognitive stimulation. It is also an age
when the delivery of other nutrition interventions
targeting young infants, such as micronutrient
powders 7 and/or lipid-based nutrient supplements
can begin or as in the case of growth monitoring,
be continued.
• Improving immunization coverage: While there is
no specific vaccine schedule for children 6 months
of age, a 6-month contact point would fall between
the 14-week diphtheria–tetanus–pertussis (DTP)
and the 9-month MCV1 contact, and thus shorten
the gap between visits from approximately 6
months to 3 months. The six-month contact could
help reduce attrition rates for three doses of DTP
and oral polio vaccine (OPV), increase inactivated
polio vaccine (IPV) uptake and would provide an
opportunity for catch-up vaccinations. The six-month
contact could thereby help reach the Global Vaccine
Action Plan (GVAP) goal of attaining 90% national
coverage and 80% coverage in every district for all
vaccines in national programs by 2020 8.
Establishing a six-month contact point may reduce missed opportunity for saving lives, improving infant and child feeding practices, improving immunization coverage and spacing births.
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• Birth spacing: Six months after birth represents the
end of the fertility protection period for a woman
who has been practicing LAM to reduce pregnancy
risk 9. It therefore is an ideal time to provide
counseling in family planning and birth spacing
methods.
PROCESS OF ESTABLISHING A SIX-MONTH
CONTACT POINT
Several countries in Africa—Côte d’Ivoire, Niger,
Senegal, Sierra Leone— have successfully piloted
the 6-month contact point and are currently
scaling it up as an opportunity to administer VAS
and other vital health and nutrition services. While
the process for establishing this new approach
varied, the following represent vital steps and
activities necessary to program success in all four
countries:
Ú 1. ADVOCACY:
Introducing a new contact point into an established
health system is challenging. It is therefore vital to
meet with key stakeholders (e.g. Ministry of Health
at national, regional and district levels; development
partners; researchers) to build consensus and clearly
explain the rationale, benefits and costs of
establishing a six-month contact point. Advocacy
targeting the national Expanded Program on
Immunization (EPI) services is needed to integrate
the six-month contact point into vaccine-related
planning, reviewing and monitoring activities (e.g.
comprehensive multi-year plans, annual program
reviews). This advocacy is also needed to integrate
the six-month contact point into the immunization
calendar and into implementation and coordination
activities of immunization teams at all levels of the
health system.
Ú 2. IMPLEMENTATION:
In many countries a ‘pilot’ phase was vital before
establishing the six-month contact point at a
national scale. The pilot phase allowed countries to
identify and develop needs related to health worker
skills, supply (e.g. VAS, contraceptives, IYCF
materials), supervision, information systems (e.g.
integrating six-month contact point into the routine
immunization schedule and into the Child Health
Card), and demand generation. It also allowed
countries to compare coverage of VAS, vaccination,
family planning and IYCF services with and without
the six-month contact point to establish its value.
Moving from the pilot phase to large-scale
implementation requires dedicated effort and
resources to successfully establish the six-month
contact point into health services. A geographically
After six months of age, it becomes increasingly difficult for breastfed infants to meet their nutrient needs from human milk alone and complementary foods should be introduced to make up the difference.
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Moving from pilot to large-scale implementation phase, requires dedicated effort and resources to successfully establish the six-month contact point into health services.
phased approach has been used in countries that
have started to scale up this innovative delivery
platform. Throughout the scale-up phase, rigorous
monitoring is required beyond the country’s health
information system to assess the scale-up process
(e.g. number of facilities delivering the services,
availability of capsules) and measure change in
coverage for the services delivered through the six-
month contact point.
Ú 3. POLICY GUIDELINES:
Scaling up the six-month contact point from a pilot
phase often requires developing policy guidelines
that clarify which interventions will be delivered, by
whom, through what actions, for what reasons and
how they will be documented. It also requires a
“roll-out” plan including health worker training,
community demand creation, an orientation/
training plan, job aids, and a system to monitor and
evaluate the coverage and quality of this new
delivery platform.
RESULTS
• In Sierra Leone, where the six-month contact point
was compared with a control group, results showed
(i) a higher proportion of children 6-11 months of
age received their dose of vitamin A closer to the
age of 6-7 months; (ii) higher coverage of family
planning counseling (61.8% vs. <1.5 %) and higher
provision of contraceptives (44.5% vs. 0.8%); (ii)
higher exposure to IYCF counseling (62.4% vs
2.8%) and complementary feeding demonstration
(62.6% vs 0.5%); but no statistically significant
difference in immunization coverage (95.8% vs.
92.4%), possibly because it was already high
(>90%) in both groups 10.
• In Senegal, where SMS reminder messages and
phone calls were used to inform caregivers of the
six-month contact point, VAS coverage was
significantly higher at six months of age in the six-
month contact point group compared to a control
group 11.
LESSONS LEARNED FROM COUNTRY
EXPERIENCES
• Unsurprisingly, in both Senegal and Sierra Leone
there was a need to monitor and ensure the
availability of supplies needed to deliver the
services offered as part of the six-month contact
point (e.g. vitamin A capsules, contraceptives, child
heath cards, vaccines).
• In Sierra Leone, strong collaboration with the
District Health Office facilitated the uninterrupted
supply of services and commodities.
• In Senegal, the provision of an initial stock of
vitamin A capsules based on census data ensured
an adequate supply at the start of the program, but
a system to monitor and replenish dwindling
supplies was vital 11.
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Scaling up the six-month contact point from a pilot phase often requires developing policy guidelines that clarify which interventions will be delivered.
• An SMS-based system that regularly reports on the
stock of supplies helped prevent stock-outs in
Senegal 11.
• In Sierra Leone, there was a need for extensive
training of health staff on the use of the revised
child health card and other components of the
six-month contact point.
• IYCF counselling, whether provided at a six-month
contact point or not, requires supportive
supervision and incentives, and is enhanced by
demonstrations.
• In Sierra Leone, the presence of a dedicated and
trained nursing aid was needed to provide family
planning services as part of the six-month contact
point. This may not be needed if all clinic staff are
trained in family planning. In Côte d’Ivoire, the use
of SMS “appointment reminder” messages
significantly increased the coverage of
immunization and VAS at six months of age (Penta
1: 86.6% vs. 76.1%; Penta 2: 81.0% vs. 67.3%; Penta 3:
74.2% vs 58.3%; VAS: 64.7% vs. 40.7%; MCV1:60.7%
vs. 37.8%) 12.
• In Senegal, demand generation and community
awareness strategies that included multiple
channels (e.g. social mobilization activities, radio,
brochures, posters, SMS reminders and community
health worker follow-up) was important for
establishing the six-month contact point.
PAGE 6
1. M. Labbok, “Postpartum sexuality and the lactational amenorrhea method for contraception,” Clin Obstet Gynecol, vol. 58, no. 4, pp. 915-27, 2015.
2. Z. Bhutta, J. Das, A. Rizvi, M. Gaffey, N. Walker, S. Horton, P. Webb, A. Lartey and R. Black, “Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?,” Lancet, vol. 382, pp. 452-77, 2013.
3. A. Imdad, E. Mayo-Wilson, K. Herzer and Z. Bhutta, “Vitamin A supplementation for preventing morbidity and mortality in children from six months to five years of age,” Cochrane Database Syst Rev, vol. 3, 2017.
4. R. Kupka, K. Nielsen, C. Nyhus Dhillon, J. Blankenship, M. Haskell, S. Baker and K. Brown, “Safety and mortality benefits of delivering vitamin A supplementation at 6 months of age in Sub-Saharan Africa,” Food Nutr Bull, vol. 37, no. 3, pp. 375-86, 2016.
5. WHO, “The optimal duration of exclusive breastfeeding: report of an expert consultation,” WHO, Geneva, 2001.
6. PAHO/WHO, “Guiding principles for complementary feeding of the breastfed child,” PAHO/WHO, Washington DC, 2002.
7. WHO, “Guideline: Use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6-23 months of age,” WHO, Geneva, 2011.
8. WHO, “Draft Global Vaccine Action Plan: Report by the Secretariat, Sixty-fifth World Health Assembly. Provisional Agenda Item 13.12.,” WHO, Geneva, 2012.
9. J. Cleland, I. Shah and M. Daniele, “Interventions to Improve Postpartum Family Planning in Low- and Middle-Income Countries: Program Implications and Research Priorities,” Stud Fam Plann, vol. 46, no. 4, pp. 423-41, 2015.
10. M. Hodges, F. Sesay, H. Kamara, E. Nyorkor, M. Bah, A. Koroma, J. Kandeh, R. Ouedraogo, A. Wolfe, H. Katcher, J. Blankenship and S. Baker, “Integrating vitamin A supplementation at 6 months into the expanded program of immunization in Sierra Leone.,” Matern Child Health J, vol. 19, no. 9, pp. 1985-92, 2015.
11. C. Thiaw, A. Cooper, C. Tendeng, M. Beye, K. Thiam, A. Thiam, H. Katcher and J. Blankenship, “Routine delivery of vitamin A supplementation at six months in Senegal using SMS reminder messages,” in Micronutrient Forum, Addis Ababa, Ethiopia, 2014.
12. R. Dissieka and D. Doledec, “SMS reminders and vocal messages increase adherence to immunization and 6-month vitamin A supplementation,” in Micronutrient Forum, Cancun, Mexico, 2016.
REFERENCES
This policy brief was prepared by the GAVA Secretariat, with support from its core partner
agencies: Nutrition International, Helen Keller International and UNICEF. © GAVA 2019
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